Confidential reporting – industry speaks out

Industry concerns over confidential incident reporting were under the microscope during a one-day Regional Aviation Summit on March 9 at Parliament House, attended by all prominent regional operators and numerous parliamentarians.

RAAA members concerns were articulated by Malcom Sharp, Chief Pilot and Managing Director of Sharp Airlines and Chair of the conference’s Technical Working Group:

“The recent moves by CASA to fully access reports provided to the ATSB through proposed changes to the TSI [transport safety investigation] Act and the draft of CASA’s Part 119, illustrate the inherent conflict in having the safety enforcer in charge of regulations. If I can provide a sort of layman’s example of this, in aviation I think we do a very good job of leading the world in regard to our reporting culture. We fully endorse the “just culture” principle, and as an industry we openly share information on safety related issues. CASA’s proposed changes to these regulations that have them gaining access to safety information, will basically destroy that form of reporting. If you have a young pilot who comes to you with a problem, and he reports the problem, we put in place changes to eliminate the problem, and that is a good outcome. If that young pilot doesn’t come to you because he or she fears regulatory action, then there is no benefit to safety. You might say ‘this would never happen.’ Well, it has happened, and continues to happen.

“Within our own organisation, for a number of years, CASA has been asking for us to disclose our confidential reporting information. We have refused for a number of years to do that. We have been threatened with regulatory action, and at this stage none of it has been forthcoming, thankfully.

“I went out to our pilots, and said “what would you think about if when you’re telling us about how you go about your day, you make a mistake, but you’re following good just culture principles? Would you come to us and say ‘I did this, I didn’t mean to, but look, I think everyone should know about it,’ would you be happy if I told CASA all about that?” They say, “well, I wouldn’t report it.”

“This happened recently with one of our operators who had a nose locker come open on an aircraft. The pilot reported this incident through the safety management system, recommended some changes to the pre-flight inspection, and educated the other pilots within the business, to make sure they look out for this particular error. The operator reports CASA was insistent that the company break confidentiality and identify the pilot, although they did not subsequently interview the pilot.

“CASA then audited the company not long after this event and issued them with a non-compliance notice. I think you can see the problem: if this information is not forthcoming, and that pilot in future would not bother to report it, and the safety outcomes would be less than desirable. That obviously doesn’t mean that if you make a deliberate mistake, this can’t be penalised, and our industry fully understands those just culture principles.

“Current practice allows some sharing of information between the ATSB and CASA, where it is necessary to maintain safety standards. There is no safety benefit in extending this, where it is clearly at risk of compromising our safety management systems. CASA’s recent tendency to demand full access to the safety management system databases has the potential to severely damage the safety reporting culture. If this were to be mandated, then it would be seen by employees that the just culture would no longer exist.”

Consensus on confidential reporting and just culture concepts, although a vital key to enhanced safety, is clearly still a work in progress.

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